the parties ibx says access to primary care driven by the compensation system has been part of medicine in the last that the years, with allowing primary care services -- i'm going to keep beating up on that, with allowing primary care services have not been valued. if you don't value the services you don't compensate people to provide them, they'll go do something else, the radiologist or surgeon or whatever it is. finding high-quality primary care is the week of making primary care be valued. >> i can't help but think of the women who got for a virus and

instead of seeing you went to the emergency room. this is not a typical example in this room, but i personally can think of many times when i wanted to see my primary care physician and there was inadequate and available for weeks. your only option is the emergency room. what would it run in your case? did she make the case, the system set up wrong case for her? >> we were available. broken seven days a week. the weekend of christmas was my weekend to work. we saw 95 patients that weekend. work seven days a week. we have access to imaging and most of her primary care product is and specialists have that now is a service giving up from studies that decreases the cost of care bulleted to those of extended hours by about 10%.

but it really has to be incentivized for what we're doing in terms of creating a tepid economic model that is about access that works. in this situation, the patient just wasn't used to it. she caught a friend of hers and said what do you do? in the same thing may have happened at our office, but it would've been a different point of entry. we knew we had access to electronic medical records and we may not have treated her as aggressively. we do think access is important. i think to say something about the terms primary care physician. it was invented by a co-pay. i used to be a general internist when i was in training and it was about a discipline of study. if you pay attention to what they call doctors, its because were getting ready change the way we are paid. primary care versus specialists

had to do with one economic model to control cost in the gatekeeper system and then drgs and then hospitalists are not turn as for those who are lifestyle oriented at night. [laughter] specializing to pay attention because they changed the names again. they're being called procedure list. that means for getting ready to get whacked. in the context of how we talk about those who care for us, a lot of times this economic language underneath. we talk about concierge medicine, that you has to do to assiduity payment system as opposed to a care system. i don't own particular the term primary care physician is such a bad name because primera to be a good thing, but it wasn't something i even heard training 20 years ago, but the time i was

out and look in a co-pay differential, that's for the term cannot had to do with the payment system. i don't know what the solution is, do we need to pay attention to what we call doctors or their care providers because underneath is quite often an economic assumption. >> i'm wondering how guilty billing codes are for a lot of what is going on. should the whole system be revamped or wiped out? when you think how many different codes, 10,000? it's anon believable number. in terms of discrete service is, which isn't what anybody anybody wants, right? >> let me give you great example of the problem this creates. if you think about -- i use primary care because there's a great area of being chastised. i'll put myself at risk and use it anyways. if you think about primary care

in the work and what the patient needs, it seems pretty obvious to me that a great body of support for that work would be nursing. nurses to great primary care and there's data to suggest people treated by nurses are healthy. if that's the case then, why isn't there a greater proportion of primary care delivered not by nurse practitioners, but nurses? it's not credible to me that it's a competency question because if you go to the hospital intensive care unit, nurses to lots of care for various patients and they do it well, so why not? the answer is it's impossible in many cases to fit what nurses do into billing codes so you can get paid for it.

what you pay for you get and we've got a system that has evolved that has been responsive for what we paid for. if you're going to move from a transaction-based system, in my opinion, to a longitudinal care model of primary care, then you have to move away from transaction-based payment and discrete payment and moved to budgeted payments, longitudinal payments to take care of patients for a period of time without regard to what the billing for the individual service is u.k. and then let providers,.yours, nurses and others and that they how they approach care of their patients without the shackles of being limited by what billing codes

well and will not allow for in my opinion. >> any outcomes that appear in washington because i can't find anyone with these ideas to go to when i go to see my doctor. i think that's part of the problem, patients are frustrated. if you see a good model, you don't know where you can access the model where you live. >> part of that is really communication between the providing organization, providing doctor or nurse. when we went to seven days a week urgent care clinics open until 8:00 at night, it was three years before we got her patients to understand we were there. w00t for science in the waiting rooms. we send out newsletters, stuffed in the billing envelopes and so people would say are open on

weekends? i didn't know that. so a lot of it is communication. i can't emphasize enough the access, particularly in 2013, we are used to the iphone and instant access to everything. if you wait for the 25 seconds, you're annoyed. i think you think that's true if you call up your physician's office and either they don't answer the phone or the answer the phone late or they say we have an appointment two weeks what to say, they're going to say and appropriately, i'm going to get it someplace else. it's incumbent on the delivery system to respond in a culturally appropriate manner and 2013 and offer services when people want and peer that's not always easy to do, but something we have to do on the delivery site to make that work. i just want to make one little

comment about the nurses delivering primary care. we have a number of nurses and nurse for dictionaries to operate in our diabetes initiative with diabetes educators to do a spectacular job. i would make a pitch however for the doctor when someone walks into the office and says i hurt, i got a pain in my belly gourmet had that feel right, having gone to medical school, not only does that add a quality site, better experience with our physicians tend to utilize the expensive ancillary services somewhat less. >> that's been our experience, too. >> and just to follow up, i agree completely. by the same token everyday part is, there's not a status bar

routine that is not diagnostic in nature. ongoing maintenance of uncomplicated diabetics and so forth to talk or staff to do. our nurses are way better at taking care of people with diabetes than i am. >> a real practical outcome of being able to organize that way is it's an important solution in my opinion to the primary care shortage because a busy primary care doc or, [inaudible] will be a lot to take care if a full panel of 22, 2300 patients depending on engagements and what not. if you organize yourself differently and the others to offload the work, a doctor.

huckabee ambition to go from 2500 to 5000 without crashing a doctor in the process of making everybody happy. >> but they come every two years early. >> were doing a lot of that in our organization and our 367 providers now, well over 100 are mid-level providers. i totally agree our city so far overly fair, overcast relative to a difference in training is something we have to understand and get more portable last for routine care and evidence-based care. but even within the context of all of that, what i think about what i do when i'm seeing patients, 85% could be done by somebody else. the other 15% is really, really important and what we've got to understand why we change our pay

models as we can expand primary care, all sorts of shortages are really having everybody worked to the top of their license. but we've got to understand that that 15% is because it's really important. tardis diagnostic and has to do with things particular to treating physicians have had that others have not had worked hard in different ways. they bring other things to the table. the piece we do have is extremely important to the real issue is everybody doing the right thing and the right place. i think we can. it's going to be global payment, making providers take risk and that will get us all out of fire business. >> we can open up a little to question. there's quite a few questions here. it's when you ask a question

he'll stand and say who you are, remember if you're watching on the web, send questions and assault. >> thank you. [inaudible] [laughter] even in a small country as the netherlands, with all kinds of examples of good procedures and practices. the issue is how to spread throughout the system so the system changes. i like to ask a question two.your murphy. this is a completely different magnitude, but at d.c. for major changes which you are talking about? with medicare need to be changed and made her way? pc animation doing such things? >> i see it as a combination of two things brought up and discussed by the previous panel and they're both necessary

conditions. you need to have a map, aslan was talking about, some roadmap for innovators have mapped out about sunland in place and some pathway to get there so that it's not offering a deal. the everything you need need in my opinion is it's hard to happen spontaneously without strong financial incentives needed to do so. as humans, we are creatures of the status quo. we can ensure comfort sounds and tend to like it. as long as people perceive the status quo as practical alternatives and that's generally things that are coincidently continuing to do the work and we'll see what happens if a retired to someone else. as long as someone sees the

status quo as a practical alternative, it's going to be hard to see change. one of the suggestions brought up earlier, i forget by whom this will have two fixes. we'll have 68, a little fix that you feel squeezed about and that's if you want the status quo. on the other hand, if you want to move into a new practice model for product this differently, as they were sensitive fix that you would be the beneficiary of that would facilitate your movement out of your comfort zone into some other place. i'm quick to say that's not a well-thought-out policy formula rather than just a notional direction, but she needed endpoint that make sense to people and networks with data

and you need strong financial incentives to encourage. >> just a quick comment on that, the aggregation mentioned earlier in the panel is part and parcel that you have to give providers together in a large group is very difficult to do. you really can't do that. secondly, once you get people together in a large group, you need to have the group be nimble. large parts of our health care delivery system or not nimble, where change is ponderous, iraq receives difficult to cut your way through. in order for innovation to occur and change to occur, you need people to move relatively quickly in a timely manner and unique to the data data in a

timely manner and all those things are intertwined. [inaudible] >> i'm not sure i agree with that. terror groups like yours and in our case were not huge. her 75 doctors in another 50 ancillary care providers. we were able to make decisions because we have a relatively small cadre of people who can make decisions and move the group in a different direction. we have a great relationship with hospitals and towns away lovett are more closely, but to get decisions at a hospital is a much different process because there's a lot of different stitches and sees served in those places. it's hard to miss that type of organization rather than an

organization focused on a mission. >> if were going to be having a system from the one of the big risks we have right now is they tend to have the capital out there, so they tend to be the aggregator physicians and other services that many people think that model is that linksys to the future. the issue of nimbleness is extraordinary and a lot has do with the high fixed costs. they've got to feed the beast and until we figure out some and quite disruptive to that, i don't think you can have anything adequate to where we need to go for a sustainable health system. having said that, north carolina the largest employer in most towns as the hospital. looking to invest in education and other things. right now we stand for much of afghanistan or put them in jail

is working for a hospital. if we move, we have to understand it's not going to be just lobbying related to complaints from insurance and mr. hospitaler physicians or whomever. it's big, disruptive, economic repercussions with what we can reconstruct this industry has lived across the seas. with all investments in health care we haven't had time to invest in anything else. but as we divest and change in mr. that model, it's a far deeper economic problem that even just the health care system. it's deeply rooted and everything for the last 50 years. >> one more question over here and that i will have time for. >> edward ryder from sunshine press. i read about interest groups in

washington and looking at health care, seems analogous to the other american is dictation that is failing compared to other oecd and that is education. in los angeles and some other cities, teachers are rebelling the nea and its fixation -- [inaudible] nea as a unit. they're interested in in quality education. there's been no talk of any incentive for doctors other than cash, but lots and lots of physicians take positions that pay less because they're motivated. >> by primary care physicians. >> i agree with that completely. i think that doctors go into

medicine for the right reasons. >> might it not be worthwhile to come up with reforms for doctors or groups of.yours that were performance other than what cash? >> i think a lot of doctors are taking jobs as opposed to small practice opportunities, largely for that reason. i think it's easy to come in to a basic for them. at the same token we need to make it financially practical for them to pursue the, which is at least how i look at it. i don't have to send my kids to college. don't worry, i'll just do good work. you need to have a sustainable economic system consistent with chasing the bigger engine.

>> and about what the doctor assess a person who didn't go to a frat party stated this i krebs cycle would happen when they were 35 years old or older. it's a model based on delay gratification. so at the end of that you have physicians of the hundred $60,000 in debt and their spouse if they have one ready for the big payoff, status going down. economic uncertainty. we were selected for medical school because we liked risk. we were selected to medical school because we are risk-averse and general as a profession or model into a period when you say what could motivate folks coming have to think about physicians. you have to get to the better nature. it's got to be about the patience of my luminaire. you'd also have to think about the money.

if you have a system that's going to be physician led in debt than they are still think the the ability do it in a way when they make the screen are again with a society now changed 20 years after they made it in stating to do that krebs cycle, you've got another thing coming. once you got that right, you'll get what you want to do because it's incredibly exciting now my organization when we say we have added business in three years are made done it. during the next three years are going to give you a guaranteed salary and they want to change everything. it's not a high salary, but we want to change everything to do the right thing in quality. it has changed everything in our group in terms of our physician behavior. >> i think many groups including ours are moving to compensation

systems that are at least partially based on quality. we are living also in a world where the rabbit will other route will or product to the wheels this part of the system we deal with. what we've done is to change our compensation system so a percentage of our physicians compensation is based on quality metrics and eventually are going to have quality metrics and patient satisfaction to a much larger percentage, which is to some extent what you're talking about. [inaudible] >> which is a wonderful thought. i'm so sorry, but we've run out of time on this panel. i'd like to thank dr. claffey, dr. murphy, dr. terrell.

tokamak >> our next panel take apart everything up to now and add some thoughts as well. >> once again, thank you for distinguished group of panels we've had. give them another round of applause. really to create panels. i now invite you to save her third and final panel will be coming around handheld microphones for the panel of experts q&a portion. we encourage you to use our twitter hash tag mj medicare. joining maggie on stage now we have dr. juliette cubanski come associate director program in medicare policy at kaiser family foundation. debbie curtis, professional soccer housemaid mean, jay cost/has helped counsel the senate i nantz committee. megan mccarthy, policy analyst and former national journal health care and dr. dana safran

of measurement and improvement of blue cross blue shield of massachusetts. i think we have everybody. alternate back to you. >> thank you very much. this is the juicy panel because were going to take all these ideas and translate them into how we can actually implement them, we can actually do given the political reality in washington, given the current situation. i think everybody here -- i can see you responding in the audience. i also want to make one important statement that these thinkers are not just academics. dr. nichols is still here, listening to the real people talk. i see dr. ginsburg were here. they just left, so we know everybody is listening to each other. the reality is that arming the

academic thought as well. it's important to note washington because sometimes you think people are disconnected from one another. here on this panel i hope you all can bring it all together. first of all, i think we can just start off, do you have any immediate thoughts and what you heard today? j-juliett, you're nodding your head. i can see you being very involved. >> what i think is quite interesting about the first panel discussions are fantastic and brought a really interesting and important aspects of problems with our health care system today and some great suggestions for ways we can move forward towards a higher performing health care system. not just medicare, but all of us. people with disabilities, but everybody because doctors who treat medicare patients

dr. street medicare patients. they treat the rest of ssl. but i think is interesting is your washing 10, were in the midst of deep thought, deep discussions about budget realities and medicare faces financial challenges, but it's not just a medicare problem. it's a health care cost problem. but nobody has yet uttered at the initial cbo found that the congressional budget office thinks will achieve budget saving is where policymakers focus a lot of their attention. so what we're hearing now with wings like to raise the issue of medicare and increase premiums that medicare beneficiaries pay in charge denmark are sharing. these are things that i'll have real dollars associated in terms of savings. we're not hearing him talk to manage about the financial

incentives that doctors face and ways to encourage greater care corp. nation. some of that was started taking care of or at least rest preliminarily in the affordable care at. ..

unfortunately that is the environment that we are living in. it was a very interesting panel especially the last one. there is nothing better than congressional staffers actually hear from people who practice medicine.

you know, patients are going through their treatments. one of the things that the reality that we suffer with, unfortunately, and this is something we all have to deal with, it is just a physical reality. as he rightly pointed out, it is right now the debate about budget and people are trying to figure how to control costs and figure out savings that are scored by studios. the cbo gets a lot of bad rap from people. but i am a fan. they have a very tough job to do. they always come out and it's a very tough job that they have to do and it's hard to please everyone in a town like washington dc and they try to be the best that can. i afford a lot of respect to them. at the end of the day, that is the reality that we have to

operate under. so we get a lot of ideas from utah, we have the great health care system, which is a lot of integrated health care delivery reforms in the most amazing things that are being done on the coordination site. so we are lucky to have this working model. they have great lessons for us. then we have to move on to an exercise that encompasses us. the lesson that i will say is that we are now in an environment where all of the the low hanging fruit is gone, just to be cannon. just to be candid. well, i completely appreciate those thoughts.

we have to look at ideas that are scored a goal. at this point come once again i can only speak for my office and my boss and we are much more deeply engaged on the side because we do believe that at the end of the day, if you really want to put an actual consisting downward pressure on health care costs, the way to do it is by reforming your entitlement system. health care delivery reform is part of it. it is a two-part solution. it's not that we can just focus on one but look at the other because it's more tough to do at a later date. i think the time has come to swallow the tough medicine and start being aggressive together. from the other side of the aisle and the other side of the capitol, this has been a really interesting panel. a discussion that we need to have a lot more of. i start off by saying that, you know, with we have the status

quo that is not sustainable with medicare. we are selective group who has chosen to be here at this conference and involved in things around washington and around the country to try to change this. for every rochester there is change that is being fought every day. so we have to figure out a way where we can get this conversation much more out across the country and to those single practicing physicians who do not want to change. my next thing is that change is hard. when you have been doing something, when my computer system changes at work, i freak out for a couple of weeks. to think about how you change this position and change the way we deliver care to drive value is a much harder thing to think about them we do have great private sector examples. whether or not financial incentives exist.

look at kaiser permanente. they get paid less than they would fee-for-service medicine. and people flock there because of the quality of life and people go to medical school not to deal with insurance companies and have all the different paperwork. they want to practice method medicine at kaiser. there are lots of other examples like that that are growing around the country. so we have to figure out how to incorporate them into the system. again, my kind of statement, everyone has their one little statement, mine is first, do no harm. what i see that we are having about entitlement reform, which is maybe not so much about reform, is that we have a situation where we pass this and everyone can say nice things or complain, but what that law has done is build process. other demonstrations that are

built to test new delivery systems and figure out if they work. so they can move forward without congress having to interfere again. that is a very important thing. if congress decides that we need these random made up numbers that we have to pull out of the medicare system, i just remind everybody that we did that and simultaneously, republicans say that you took all this money out of medicare, but then we have to cut even more out of medicare. it does not make sense. i think you have to be very careful on the medicare side that we don't pull so much out that we endanger the ability of all this innovation to move forward. and we endanger the ability of doctors to be engaged in the medicare program and that goes to finding a solution, which

again, i can't remember who said it, but we need to build this into the system. as long as we continue to have this out here, we are not able to think long-term and do the things that we need to do in the medicare program and across our health care system. so i guess my number one thing is let's look at the facts. because of this and other changes that are going on, we have lowered the growth rate in medicare and that has never happened. we have really lowered the growth of medicare. in doing that, we are creating tremendous savings for the government, but we are not secure right now. and we need to preserve that. we need to achieve greater savings on paper out of the medicare system, but it destroys that system for people, that is

not an outcome that is a good outcome for people in our country. as much of the private sector innovation that there is, let's be honest, if the private sector can do this, we would have a health care system outside of medicare, and we do not. we do not because it takes all of us working together. most insurance companies today use crts and the payments which were developed through the medicare program's and we have to figure out how we can collaboratively work and hopefully take politics out of what some of what medicare has become an move forward in a way that improves the health care system. >> dana safran, you represent the insurance perspective, the elephant in the room. any immediate thoughts from your mind? >> it's been a very interesting and exciting morning. from the first panel to the second panel, they all have a

vision of what needs to happen. to the second panel of the doctors who also were enormously aligned in what needs to happen. so i feel like part of my role here is to inject some optimism that actually shows us that things are happening and these are not just thoughts are possibilities. so i could take just a few minutes to share how this is actually unfolded in reality in massachusetts over the last several years. really, the impetus for this was in 2007, as folks know, we began implementing our state law to extend everybody in massachusetts and have included covering nearly everyone in massachusetts, but the next mountain to climb was the early months of 2007. we knew that we had reform

payments and that payment reform had to deliver the kind of delivery system reform that would produce long-term spending growth and at the same time improve quality. so those twin goals, the holy grail, we really need to reduce spending growth and improve quality growth in 2007. the company that i work for, blue cross blue shield of massachusetts, began developing a payment model, that by the way we made completely voluntary. this is not a forced march into a system. but something that back in 2071 no one was talking about payment reform, without their is an optional model for providers and organizations that sells alliance that we could do better. really there are four things

that are just think about that model. we talked about all of them this morning. the first is that the provider organization that comes into the model takes accountability for care across the continuum and for their patient population. so everything from prenatal care to end-of-life care and everything in between is their responsibility regardless of whether they personally deliver the care or cup and elsewhere in the system. that is a very different mindset. it leads to very different behaviors and relationships and models and patient engagement models from a model that says you are only responsible for the patient's incentive through this moment. then you go for it and they will be on their merry way. so creating that kind of longitudinal accountability is very important in the difference of the model. a secondary importance is that based space on a global budget for that population. and there are sheerest savings and risks. there are all kinds of

protections. so that is not unreasonable. so that budgets are set in a way that is accounting for that population and what is taking care of that up to that point. so that the provider knows that they have all the resources that they have, but now they have an incentive to figure out where was their wasteful spending. and i can tell you that over the four years that the model has been in place now, every organization that has come into this has found significant savings and also made significant improvements in quality. these have been documented in the new england journal of medicine and not just what we're talking about. as our network has seen the successive and also for the drumbeat that now sound like payment reform is coming, there has been an adaption of the model where we now have 80% of

our provider network contracted in this way. taking accountability for total medical expenses and quality outcome. being rewarded for achieving better quality and better health the third thing that is different about the model is that it's a long-term contract and the rate of increase over the long-term is negotiated up front and comes down to look by general inflation by the end of the model. back in 2007 when we were dealing with this problem at 11%, 12%, double digits every year -- we had to cut that in half. now the economy rebounds in the contracts are scheduled to grow at a rate that will not outpace the rest of the economy so that

it is an unaffordable system. and the final piece is that we work in partnership to help them be successful in this model because we have the data in this holistic view that they don't necessarily have. many of them, most of them function under this set of incentives that are really now 180 degrees in difference. working together and profit sharing and so forth, we are actually making enormous strides and we have, in massachusetts, we are looking very differently. maggie asked about care that looks like that. you know, care that looks and feels like they care because we are very concerned about

avoiding those unnecessary emergency room visits and the things that add enormous expense. i am optimistic that, you know, we can do it in one area of the country. with the same burning platform of affordability that exist everywhere else, that this can happen and medicare can happen either way. >> okay, so we have lots of examples of what works and they are out there. almost everyone agrees on every point. so why on earth have we moved faster to reforming our system? what is the hold up? >> i think there's a glimmer of

hope on congress and the way that jane debbie had explained this. we are bringing those budgets to the fiscal cliff to perhaps create some fiscal room for more to be done for the committee that have to deal with health care. this is not just about cbo scores, but some who are maybe looking at the payment reforms and i think what has taken so long is the payment that appears and you have to have the numbers to get something to pass congress or whatever. so that has been the biggest challenge and continues to be the biggest challenge.

i am slightly more optimistic because the process has slowed down a little bit in the coming months and could set up a reconciliation process that requires less votes in senate, makes it easier to pass controversial legislation that could put medicare on a more sustainable path. >> what's the next step in congress? >> i am a simple guy, so it's hard to say. there are plenty of people who are smarter and brighter than i am. but the biggest challenge we are facing in congress, unfortunately, is this finger-pointing exercise we all do. until we start learning and work together, it's going to be a difficult year. that is something that has been made repeatedly in points.

there are some very tough decisions facing us. there are some stark fiscal realities facing us. so we can all look at the past and continue to rehash the past and keep using the same talking points or try to figure out how to move forward with this. you know, on entitlement reform side, i understand people have concerns. but that is a reality that we all have to face. nobody has the perfect answer or solution. but that has to be part of the solution that we are working on. you know, we can sit here and slice the data on health care expenditures and look at all this information and see what's happening. health care costs have gone down, but look at 2014 and beyond and see what happens to the health care costs, they bounce back up. we can either say okay, we have done our jobs, it's time to move on, or we can say that the real challenges lie ahead and we all have our priorities, but we have to work together.

let's hold hands and try to figure out a way forward. once again this is something that we have to do on a bipartisan basis. but when we talk using words like this and those kind of phrases, they don't really help the conversation. it's much better for all of us to sit down and say, okay, here are my ideas, it took an act of courage to put down the five specific ideas he wanted to put out there, and say here are your ideas, i'm putting specific policies on the table, come and sit down and talk to me and tell me what you like or do not like. that is the way we are going to have a conversation. but the conversation will immediately evolve into how we need to do it this way -- that's not good for either side. that's not good for one party or the other. this is as a whole. we have to figure out how to

work together and move beyond the talking points and say decisions have to be made. >> a lot of people agree that politics -- do you have some thoughts. is there a way to fly under the radar of politics? >> i would say on both sides, medicare is no more of a lightning rod then this panel. everyone is guilty here. i know what my former boss would say is it's really been in the past decade that we have seen medicare become the political football that it is. it is because of this wrong ideological belief that government is bad and there are a number of people who ran on a platform and continue to serve in a matter of opposing government and the reality is it doesn't exist because the government wanted to run an insurance company. it exists because the private sector was not taking care of senior citizens and there was an

agreement of the to have the government step in and create this program. pete stark would remind you that when he and bill were the chair and ranking member, there is not a medicare bill. it went to the floor in the house, there was not one that they didn't support. the recent past is not a good example but if you go back further, there was a lot of consensus on the medicare program. when we created this system, that was pete stark working in and with the ama to create a better system pay for physician services. you know, we do have to get out of this political name-calling. but it takes both sides to do that. if someone has a clue how to do it, we would all love to know. >> getting away from the politics, we are not all kumbaya on everything. julia, you mentioned one of the issues, which is raising the

medicare eligibility age. not everyone agreed that that would save money. can you address that a bit? >> yes, medicare eligibility has been around for a long time and it has gotten a lot more attention the past couple of years. one of the major concerns prior to passage of the affordable care act is that you would create a large number of people without insurance if they didn't have medicare coverage when they reached age 65. it helps to the expansion of medicaid and people being subsidized with low income, which would be beneficial to people. i think their concern with this proposal is that it can definitely remove people from the medicare rules for church

leaders. that doesn't really do anything to address the problem than we have in this country but the growth in health care costs overall. it's a the mechanism basically of shifting costs from the government to private players and employers the medicaid program and beneficiaries themselves and the people who lose access to medicare and many who would end up paying more for a new source of coverage than they would under the medicare program to put one of those ideas that we will get a score from the cbo and it will make the oscars have enough of that. but as i said, it doesn't really address some of the systemic costs and problems that we are having in this country. while there might be opportunities for coverage for people who lost their medicare eligibility, many of them, according to analysis that the

foundation has conducted, would end up paying more under their new source of coverage. so it's not quite the win-win situation that many people might think it is. >> i would also add that it's very difficult when you look at each of these things. we are not talking about one policy. if you take the asia medicare and many say that this increased needs testing, and one of the problems we have is that people don't understand how this exists in the program. if you earn $80,000 per year in the medicare program, you are considered rich and you pay an increased premium. for under 65, you have to earn before you pay any increase taxes. it doesn't make any sense. when you go into medicare, your pain to set up premiums and two sets of metadata coverage. two sets of party coverage.

just for the string of monthly expenses for health care. they escalate dramatically at a time when you have probably less opportunity to increase ever come in the future. so i think we have to be very careful when we look at the beneficiary impact of changes and we need to understand what we're talking about and how it will impact people. the posturing and medicare is very high. in order to increase the cost is a difficult thing to do. all of these things go together. so i worry you can miss some of the problems that can happen. >> i can't help but draw a parallel to the commercial side where we have had for years efforts to try to get health care spending under control by dealing with the benefits side

and inventing new benefits structures and care products and other things that would make individuals more price conscious and so forth. on the other hand, now we are dealing with the supplier side and payment reform. there's very little question on my side. but the economist that are evaluating what we're doing, they have very little question that this just so much further in the affordability goals and quality improvement goals by addressing the supply-side. putting more and more effort into the individuals. we have heard story after story about where there is rational used in our delivery system because of the fragmentation that we have. and we have seen through the payment reform that we have done

that it does actually help rationalize the system and the fabric together between the primary care and hospitals to start to understand their place in this reform the system is a cost center and not a revenue center and actually have to become smaller over time for the system becomes sustainable. focus our attention on individuals and the public and beneficiaries and how we will change this to make all the work, it just seems that there is a real problem. it's where we have structured the incentive on the delivery system side and fixing that can go a long way towards addressing the portability and quality. >> we have a very little time slot slot left. maybe he questioned her to let from the audience, if there is one.

if you could please identify yourself. that would be great. >> i can't resist. i was so impressed with the letter to colleagues. all hundred of them. i have two questions, first, did anybody come to chad and second, what comparable gesture by your boss he is welcoming from the other side? what else do we need to keep the session going? >> that's a very nice question. i will say it's been a busy week in the senate and we are hoping that her colleagues on the other side of the aisle would reach out to us in the next couple of weeks. we've had some very good chance with our fellow colleagues on the other side of the aisle. so so far nobody has come in, which is a good start the

conversation. it is -- on the other side of the aisle -- i think what we are are really hoping for the real conversation. because at the end of the day and that everyone talks about, this is a very complicated issue. there is a reason there is a transformation of medicare. there has to be a place where everybody has some part of the game. that includes the providers and easy to nitpick similar policies and say, okay, age or medigap reform or you can point out winners and losers. but you have to look at this holistic way. otherwise here's the simple truth. if we don't stop looking and entitlement reform in a

comprehensive manner, the only thing we are looking at is cutting providers. i think providers are done with that and congress' stomach that. we want them to get away from this year by year exercise where we are all struggling to find the low hanging dollars and cutting providers and market cuts and moving on to a spot where we say, okay, there are 10,000 that are joining the medicare program everyday. the program is unsustainable and people can put whatever kind of information they want and look at it a certain way. but we are on a path to insolvency in medicare. so let's try to figure out a path where beneficiaries are involved and that is all they are looking for is a holistic

conversation and we welcome anybody out there wants to have that conversation with our office. >> we have time for one more question? >> right here. >> i have a quick one for juliet. he talked you talked about some of the changes that could occur with the age of medicare. one of the things that we could morphon is how one of the five and 6-year-olds into the regular system would drive up costs with the three to one range bending under the aca. it was one of the things that was pointed out. bringing almost everybody into the system. >> we did show that there would be a premium effect for people

under the insurance exchanges, bring the relatively higher cost into the relatively lower cost insurance exchange bullets. i think it was 3% overall according to our analysis. if you implemented this in that year, we did not have any further analysis of whether there would be dropout and whether there is a potential for that. there's a potential that would really move the needle in that regard. but i would definitely have those kinds of effects, and it would also increase the premiums for those who stay on medicare. just as you're taking 65 and 66-year-olds out of the medicare pool, you are leaving a relatively more expensive set of beneficiaries behind. so there is that the meme effect

as well. >> that takes us to the end of our session and i would like to thank the panelists who have appeared. debbie curtis, jay khosla, thomas claffey, juliette cubanski, meghan mccarthy, and you also must. i will turn it back over to the mc. >> thank you so much. once again, i would like to thank the american medical association and to welcome the doctor, he is going to offer some closing remarks to us. >> well, i think this has been fantastic and i would like to thank the national journal for acting as host and thank you, connie. speakers have wonderful panels. maggie, you served as the bonding agent for the whole

thing, so thank you. a couple of comments. why is health care such a special topic? this really brings it home. i can think of three reasons. first, obviously it is too expensive for the outcomes that we secure. 70% of the gdp. second, it is awfully personal. i can say two groups like this, it is just a matter of timing. third it is very national and our security as a nation actually rests in the quality of our capital of our citizens. so where are we in this discussion as we think of panelists that represent different points of view? well, there seems to be several and i will name three points of agreement. the first is that the status quo

is unacceptable. we can sort of see a blurry vision of the future. the real question is how we transition and what is our plan for transitioning for our future. secondly, we are a diverse nation. what works in kansas is unlikely to be the solution for new york. there, a need for position leadership. not the least because physicians are the trusted agents of our patients. the work of beth mcguinn showed what is motivating satisfaction for positions. it is a primary driver of that. which is feeling as though he or she is delivering quality care to patients in relieving the administrative burden in doing

now by spending time with their patients. so that's where we are across the disciplines, where are we as the ama and our position? well, as i mentioned, we will work with a variety of other stakeholders on a transitional framework. that the principles that are available to anyone who would like to have them. we see our role in this phase to this future. secondly we are focused on value and quality care in all of our endeavors or the second one, we are focused on educating physicians in a way that will allow them to participate in this future that is more team-based and quite different than the medicine of the past. third, thinking about positions of sustainability and practice so physicians can do what they love to do.

and that is take care of patients. last, let me say that as a recovering dean and hospital ceo and now ceo of the ama, there weren't always try to jump in and adjudicate early conflicts before they blow up. so with all of you in mind, i would like to say that there is nothing more elegant and primary care. [laughter] [applause] >> next on c-span2, senators speak on the confirmation of john kerry at the next secretary of state. after that, if the nets held subcommittee examines the shortage of primary care physicians.

later, in national journal forum looks at medicare costs. coming up on the next "washington journal", a look at the newest push for immigration reform. former bush administration commerce secretary, a member of the super pac republicans for immigration reform, will be our guest. then "new york times" columnist paul krugman discusses the economy and his new book, and this depression now. later, our spotlight on magazine series continues with robert draper of national geographic. "washington journal" is live starting at 7:00 a.m. eastern on c-span. thursday, the president's nominee to be the next defense secretary, chuck hagel, testified before the senate armed services committee. he learned coverage at 9:30 a.m. on c-span and c-span radio.

>> georgia o'keeffe was really the first well-known woman artist. even well into her life in the 1970s. there was no one who could match her. she became a feminist icon and i grew up under the influence. my first recognition of her work was as attention drawn to these fabulous paintings and i lived in colorado and people talked about this woman and the way she lived. the fact that from 1929 forward, she came to mexico for several months out of the year, living apart from her husband in the '30s and 40s. she continued to do this until her husband's death, and then she moved to new mexico full-time. so she lights up our imagination as an artist. because he was famous so young

and secondly, she lived the life she wanted to live and she was a very disciplined woman. i think that stands out as women made choices even right through to the 70s. they made choices that accommodative family and other pursuits in their life. georgia o'keeffe had one driving passion. >> georgia o'keeffe is featured this weekend. saturday at noon eastern, we discover the literary life of santa fe. >> the u.s. senate confirmed massachusetts senator john kerry to be the next secretary of state by a vote of 94 to three.

voting against him were senator cornyn and senator inhofe. next, senator menendez, senator corker, and senator cardin on the nomination. this is 20 minutes. >> the senator from new jersey. >> madam president, i rise to speak to the nomination of senator john kerry to be the next secretary of state. it has been more than 100 years since a member of the senate foreign relations committee was directly nominated to be the secretary of state. the last was senator john sherman of ohio that was selected to serve as secretary of state to president mckinley. i think it's important to note that this historical fact exist because senator kerry's path is not one commonly taken, but one that is earned by a select few. and he has earned this opportunity. from the first time that john

testified before chairman fulbright and a young, returning vietnam war hero in 1971, to the date of day that the president announced his nomination of secretary of state, he has invested himself in all of these endeavors, always looking for the truth. uncovering the facts. hearing all the evidence. and then publicly speaking solely on what was best for this nation. i know that he will carry those leadership traits with him into his new position and i can think of no one better prepared to take on the challenges of this position. as a senator and member of this committee, and as the chairman, john has already built strong relationships with leaders across the world, which will allow him to step seamlessly into the role of secretary of

state. senator kerry needs no introduction to the world and military leaders, and will begin on day one not only with the intricacies of foreign policy, but with an understanding of the nuanced approach necessary to effectively interact on a multinational scale. excuse me, stage. when vice president biden was chairman of the foreign relations committee, said on more than one occasion that good international relationships are always predicated on strong interpersonal relationships. john kerry understands that there is no substitute for strong interpersonal relationships, whether in the senate politics or international diplomacy. secretary of state is not a desk job and it requires constant personal interactions for american foreign policy. during his 30 years in public

life and more than 25 years in the senate, senator kerry has championed many issues. earlier today the senate foreign relations committee favorably reported his nomination to the senate unanimously and presented senator kerry with an honorary resolution highlighting a few of his many accomplishments. among the accomplishments are the reforms with senator john mccain that led to an effort to investigate the fate of american soldiers unaccounted for in vietnam. he normalized relation with a former enemy, which is in essence, vietnam. it is a conference of investigation in the senate on everything from the bank of credit and commerce international and illegal money laundering. advocating for democratic elections in the philippines and serving with senator dick lugar is part of the senate delegations that led to the ouster of ferdinand marcos.

working with the cambodian government, they prosecuted key members. advocating for programs that help so they don't fall in the hands of hostile states and terrorist. during the arab spring, senator john kerry supported an effort to save thousands of lives from being massacred. john has been a tireless advocate for the cause of the south suzanne success he has

worked with bill frist on hiv aids legislation that laid the foundation of the president emergency aids relief program, a program that provides life-saving treatment for it those with hiv and aids and who supports broad prevention efforts would save lives everyday. john supports the transition to a clean energy future as well. as chairman of the committee on foreign relations, he convened a major hearings and roundtables and underscores the connection to global stability. economic competitive ways and american security. his portfolio will represent the interest of the nation. securing and protecting overseas

personnel promoting commerce and enhancing ties in keeping america secure with cooperation were possible. whatever the challenges are that we will face as a nation, in my view this could not be in better hands. when it comes to america's role in world affairs, i know that we all agree that it is credible that the united states remains projecting that military strength but the wisdom of our democratic ideas. i have no doubt that senator kerry will rise to meet these goals. i look forward to working with them as they move forward in the days ahead.

all members will say that even when they did not agree with chairman john kerry on a given issue, they can could always feel that he had an open ear. an open door. an opportunity for a full debate in an effort to seek common ground, particularly in u.s. foreign policy. that will serve extraordinarily well in his role as the secretary of state as he deals with the senate and house of representatives as part of promoting u.s. foreign policy abroad, bringing it cohesively as possible to promote the security of the united states. so i look forward at the end of this time to a strong confirmation vote as we send a message that world that this is our secretary of state and he speaks for america on behalf of the obama administration. that, i yield the floor.

>> the senator from tennessee. >> thank you. >> i want to thank the chairman for holding this hearing. the way that paulson politics are in washington, sometimes it seems that we can't be happy for someone on the other side of the aisle and nothing could be further from the truth, and i would just like to say that i thought that senator kerry acquitted himself exceptionally well in the hearings that he had last week. i thought they were wide-ranging and i thought that he had the opportunity to display and anyone who has lived a life that has been touched by john kerry,

i am happy for him and his family and the fact that he will be able to express himself. his dad was a foreign service officer and he certainly made a splash, some people thought it was negative, others positive, he certainly made a splash during the vietnam era and from that point on has been very active. again, i thought he acquitted himself exceptionally well. just because of some of the things that have happened in libya, we have a state department that needs oversight, and we haven't provided it. we are providing it now for over a decade. i know that he sees the need for the senate in its authorization process to be involved and be

involved with him as we tried to call this organization that over the years is just built-in to sporadic identity. a lot of times when a political person comes into an organization, the bureaucracy tries to wait it out until the next person comes along. i look forward to working with the chairman in any way that he ends up deciding that we can work together on this particular issue to really look at the state department. i know we most recently had a hearing with senator clinton on benghazi, and it has been an accountability review board recommendations that have been put forth. i know that senator kerry said that he certainly is going to see those through and make sure that they are fully implemented. i know we talked a great deal about the hearing and we have done so personally with a

nuclear posture and modernization, which is what we discussed during the start treaty. it's something that i supported him on. i found his comments about where we need to be in that regard certainly reassuring. i also think that he's very clear as it relates to the threat that we face, especially in north africa, but in many places a list of terrorist groups like al qaeda. i think he wants only the best for our nation. i'm sure that he will take positions and in some cases, maybe senator menendez will not

exactly do the course of action that actually ought to be taken on behalf of our country. but my sense is that he will be open to listening. and i think that he will be willing to sit down and talk about that as we move ahead. i think that it's good for our nation we live in a world where things change on a daily basis. look at the things that occurred a week ago. i think you have someone like

senator kerry who spent a lifetime on these issues, understanding that history and institutional issues have bound us or separated us from these countries, i think having someone like him representing us could be a very good thing. i joined in the chairman with supporting him and i know many will have comments about service in the senate and also the future service and i look forward to listening to that and i yield the floor. >> the senator from new orleans. >> yes, i just want to urge our colleagues to pump we confirm senator kerry as our next secretary of state. it's a great honor to serve in the united states senate. it's a privilege and honor to represent people here in the united states senate and part of that special privilege for

people that we serve white. incredible public servants that we have had the privilege of serving life in the united states senate. i put senator kerry at the top of that list. he has devoted his life to public service. he is so qualified to assume responsibilities of secretary of state. he understands this complex world in which we live in. and the differences among countries. many are strategically important to the united states if they don't share our values. senator john kerry understands that. he understands the importance to advance u.s. interests and we need to understand concerns of other countries and we need to establish relations with other countries. he's made a personal commitment to understand the world in which we live and area i don't think there's been a member of this

body that has spent more time, going to more places, met with more people, in order to represent our nation on the international stage. senator john kerry has always done now with the greatest degree of competency and representing our country and the fondest traditions. he has experience as a soldier serving in vietnam and experiences as a senator of 28 years, representing the people of massachusetts in the united states senate. we know about the senate foreign relations committee and i want to talk about two other committees, the finance committee that i had the ability to serve as well. no one understands the impact that our fiscal house has for our national security interest. in fact, i was very pleased at

the mentioning of the need for us to get our fiscal house in order, and he is one of the, i think, he understands that and understand the commitment. he has once confirmed heading the state department to help us in bringing about fiscal sanity here in the united states to do what is necessary worldwide and to do it in the most cost effective way. i also served with senator john kerry on the small business community and they didn't have a better applicant. i was pleased with how many times we help small business and help america grow. clearly it has been these last two years that i've had the privilege of serving with senator kerry as he has chaired the foreign relations committee and his ability to carry out so

many important responsibilities senator john kerry understands that our national security depends upon a strong military diplomacy and international development assistance is less than 1%. you know, we spend on our military and it's a lot larger than that. all three are important to national security. senator john kerry understands that. he understands that with diplomacy we can avoid unnecessary military action. he understands that with diplomacy, we can make america safer. he understands international development assistance and we can strengthen our country and

make it more stable and less likely to use military. that's the type of leader that we need senator john kerry will follow in that tradition. take a look at senator john kerry's record of advancing america's interests. we have a safer world today due to senator kerry's efforts. as you know, we approved the new start treaty. the announcement of nuclear weapons between the united states and russia. that makes this world safer. his record on human rights is well known. many other places around the world as well. he has been a leader in advancing the cause of human rights. we already heard senator menendez point out that his efforts were great in vietnam and he represented america and our pows mia.

that is unprecedented to be able to go to a country that we have war with and have that affect us. he used his talent to be able to bring closure to many american families. we were then able to improve our relationships between the united states and vietnam. recognizing that it's in america's interest that we were able to communicate with other countries. ..

senator kerry was one of the great advocates to advance america's leadership internationally to stop human trafficking. he's protect the people with disability. as senator menendez mentioned he's been our leader on climate issues, recognize the importance that the united states to demonstrate international leadership in order to deal with the global problem, a problem important to deal with as a citizen of the world, but also to deal with in regards to america's economy and energy needs and america's responsibility as far as security is concerned. senator kerry, has been a great leader on that. he's provided leadership for humanitarians. the personal commitment each of you make sure america was in the

leadership in a country that suffered such a horrible disaster and hemispheric and his work there is extremely important. he that effort on dealing with hiv/aids in the response of a thing as far as the americans position on that. he understand the importance of development assistance against gender equality. it's very interesting we take a look at the health of the country, look at the way they treat their women. we have a strong commitment to spurs international development assistance around the world. we need to use that to make sure conscious advance rates were immense. it's only write for what we believe in s. america, but also that we are at table country revelation space. senator kerry understands that. he's been one of the leaders attending corrections. bloggers member of the hearing our committee when former president clinton in oblates testified before us.

they have a zero policy dealing with countries that can't control corruption. they want to make sure their assistance doesn't have corruption. senator kerry understands we don't want assistants to be used to feel corruption. that's the type of leadership we need as the secretary of state. the list goes on and on, not an president of what he's been able to do to advance the right adventures the united states. i'm confident that her carious legacy of human rights and global peace will continue as he assumes to responsibility as secretary of state for the united states of america. here's my colleagues to support his nomination. i think chairman anand as for bringing this nomination to the floor so quickly hexameter corker for accommodating it. it's important president obama has the payment place as quickly

as possible and i'm proud to senate will do its share of its work for voting for this nomination later today. with that, madam president, i suggest the absence of a quorum.

>> all of us were tired way before we got to the white house. the white house just by sending our miss push-up. the darndest thing, i think the ladies would agree that the day before you are married to the president-elect, nobody gives a darn what you say. and the day after he is the president-elect, people think you're brilliant. last march [laughter] [applause] >> currently, 30% of u.s. doctors are primary care

physicians. tuesday the subcommittee and primary health examined the growing shortage of primary to yours. this is just under two hours. [inaudible] >> -- which is going to cover an enormously important issue. i want to thank her ranking member for his word. he and i worked together in a number of issues over the years and i look forward to a project working relationship. vermont is a rural state. i know something about moral problems. his status a lot more rural, so we will see how we can go forward together.

in our country today, before it became not, let me thank all of our panelists for being here. we have a great set of panelists from all over the country and we very much appreciate them being here and we thank them for the work they do every day providing health care and doing research. in our country today, as many people know, we spend almost twice as much as to the people of any other country per capita on health care. that's about 18% of our gdp and the other health care outcomes in terms of life expect to see come into mortality and disease prevention are not particularly good in terms of international comparisons. one of the reasons for that is we have a major creases regarding primary access, which results in low quality health care for people in greater

expenditures. low quality health care commander because of the crisis and primary health care spending substantially more than we should. today, 57 million people in the united states, one in five americans cannot see a doc or when they need to create lack of access to primary care provider is a national problem, but those most impacted are people who are low income minorities and the seniors and people who live in rural communities, whether vermont or wyoming. as we've seen time and time again with agile care, mental health and other health care issues, the groups that need health care the most are the least likely to receive it. the good news is just 11 months from now we will be providing health insurance to 30 million more americans are the affordable care act. the bad news is we don't know how we are going to be providing

primary health care to those americans who now will have health insurance. let me just battle at some statistics that i think should be up to turn for the congress in effect to all americans. not widely known, but maybe dr. wilper will talk about this. they died because they do not have health insurance and they do not get to a doctor on time. 45,000 americans. according to the health resources and services administration, winning 16,000 primary care part missionaries to meet the needs that exist today with a ratio of one provider for 2000 patients. over 52,000 primary care physicians will be needed to

2025. in 2011, about 17,000 is graduated for the american medical schools despite the fact over half of patient visits offer primary care, only 7% of the nation's medical school graduates now choose a primary care career. 7%. nearly all the growth in the number of the first per capita in the last several decades has been due to a rise in the number of specialists between 1965 in 1892, primary care physician ratio grew by 14% while the specialist population ratio exploded by 120%. the average primary care physician the united states is 47 years of age and one quarter during your retirement.

in 2012, it took about 45 days for new patients to see a family doctor up from 29 days in 2010. another, if you can find a family provider, it often takes longer than it should to see him or her. only 28% of u.s. primary care practices provide access to care on evenings, weekends or holidays. that's compared to 95% positions in the united kingdom. in other words, cultures don't get sick on saturday, sunday or night. not a file clockworks good. past of patients would have gone to a primary care provider if they had been able to get an appointment at the time one was needed. in other words, were wasting billions of dollars because

people end up in the emergency room for non-emergent care because they can't find a primary health care physician. in my view in the view of experts who studied the issue, primary care is intended to be and should be the foundation of the u.s. health care system. in 2008, americans made almost a billion office visits to the doctor. 50% were to primary care doc nurse. according to virtually every study done on this issue, access to primary health care results in better health outcomes reduce health disparities and lower spending and not only reducing emergency room, but when you get people to the doctor when they should, they don't get sicker and end up in the hospital a great price.

the problem were discussing is clearly a national problem existed in 50 states in the country, but it's even worse than particular geographic regions. the ratio doctors in urban areas is 100 per 100,000 people. double the ratio in rural communities where it is 46 per 100,000. urban communities clearly have problems. rural communities have even greater problems. 65% of health care professional shortage areas are in rural counties. in my own state we do much better than the rest of the country in terms of primary health care providers per hundred thousand yet i can tell you the state of vermont, people often have difficulty getting to the primary care provider thingy. although 20% live in rural areas, only 9% of physicians for this they are.

one of the differences between the u.s. health care system are highly developed countries, which could explain why we spend more than other countries around the world is the ratio of primary care physicians to specialists. and the united states roughly speaking, 70% of part tichenor's her specialists. or to% are health care providers. around the rest of the world, the numbers exactly the opposite. 70% of practitioners are primary health care providers, 30% specialists. what can congress do to address this serious issue? that they rattle off a few points and get to make to senator enzi. first and foremost, we must address the issue of primary care reimbursement rates. specialist aaron as much for their lifetime apart is,

$2.8 billion more than primary care providers. if you're going into medicine, you can resurrect their lifetime and earn $3 million more than a primary care part titian. radiologists and gastroenterologists have an comes more than twice that. the system in this country is largely determine the physicians on the american medical association committee the rock by the census for medicare and medicaid services and are adopted by private insurers. specialist on the committee determine reimbursement rates. we have to look at that issue.

medicare has promoted the growth of residents use the specialty fields by providing 10 billion each year to teaching hospitals without requiring any emphasis on training primary care doctors thirdly, unlike other nations, which provides significant financial support for medical school education, we buy a large do not do this in our country and the result is the median debt for medical students on graduation is more than 100 xt thousand in almost a third of medical school graduates leave school for the $200,000 in debt. if you leave school $200,000 in debt, what are you going to do? figure out how to make as much money as possible and gravitate towards those fields which pay you higher incomes. so if are going to attract young people in primary health care,

we must make that profession more financially as. in other words, addressed the issue of how reimbursement rates are set for medicare, which in tax rates for all physicians. in recent years the network on this issue, we have greatly expanded community health centers around the country and community health centers provide very good quality, cost-effective health care. we need to do more than not. we made progress, we need more progress. in recent years we significantly increase funding for the national health service call. if you're graduating medical school, work one half you address that data. i'll help you pay it off if you practice in areas. it is working, housework, we need more progress than not. teaching how centers. studies have shown residents

train rural communities are more likely than those in other settings to make a career practicing underserved or rural areas. they teach the program is domino investment in medical education and the affordable care act in a five-year funding was only $200 million. got to extend that concept. most of a hard look at allied health providers, nurse for tichenor's and how to better utilize those people in the position of health care. we got a very, very serious problem. dozens of people depend on what we do and i'm very excited about the wonderful panelists we have at this hearing and on the dearborn center enzi presents so much work in this area. >> thank you, mr. chairing. i'm glad to be joining you as ranking member of the subcommittee and i look forward to working with you.

q-quebec do you think witnesses for taking time out of their schedules to be with us. a day to welcome tony duck liver from cheyenne peerages work with him a stuff on workforce issues for a number of years and i appreciate me the long trip across the country to be here. it's a pleasure to welcome all witnesses to her hearing. the shoot and print access to primary care services and the landing health care workforce is one important to all of us, but especially to the cat given the obstacles people face in wyoming. nearly the entire state is considered a frontier or rural county. 47% of the population lives in the county with fewer than six residents per square mile. according to the wyoming department of health, 200,000 residents within health professional shortage areas with inadequate access to primary dental care. serious challenges require creative solutions to resolve. we have one hospital served by a

physician that every time we lose the position the hospital closes. two gunmen, state develop programs tailored to meet the needs of a frontier state where distance presents the biggest pair to access the.dirt, we say we have miles and miles and miles and miles and recruiting health care professionals who live and work there is an ongoing challenge. the wyoming department of health operates its own on repeated program along with the physician recruitment grant program. these programs work to reduce the high cost of health professional graduate training programs, often a deterrent to work in primary care or other lower-income medical. by wyoming resources network represents another innovative approach improving access and reducing primary care workforce shortages. this collaborative arrangement between major medical and health professional societies,

university of wyoming and other partners maintains an extensive database on health care facilities and the need for professionals. sharing information more effectively allows for better allocation of resources and man power to time in the fiscal climate limits our ability to spend money on the problem. there's more that can be done to better align federal programs to meet the needs of rural and frontier states. the criteria to determine eligibility for funds to support program are based on factors that make it difficult to prove needs of underserved and frontier areas. for example, one provider for 3500 people in new york city is entirely diff and from 3500 people in fremont or campbell county. in addition, when you think more creatively of technology services to improve telemedicine capabilities so worried for less impact on the level of care they are able to receive come

advancement of more powerful wireless technologies has substantial potential to link individuals across the country to deliver health care more accessible settings. we've had quite a bit of success for some veterans outreach clinics where they used medicine extensively with the nurse practitioners in charge of handling to quit and an adapter on the other end of the telemedicine. i hope this time will make it clear we need to think more creatively and figure out ways in which all americans can better access primary care services and waste to ensure health care professionals are employed were most needed. i look forward to hearing witnesses and what needs to be done to solve these problems at the federal, state and local level. what you think witnesses for their participation in the chairman for his great list of suggestions on things that need to be done and i'm sure with the capability to come up with solutions.

>> senator enzi, thank you very much. senator warren was here first. [inaudible] >> i just want to thank you for holding this hearing, mr. chairman. i am very interested in the question about how we equalize access for citizens and particularly on how we make the right investment to lower the overall cost of health care. the chairman said it best when he said what we are looking for is better outcomes at lower cost and that is the picture real role the federal government could make if it makes the right up front investment. i'm look forward to hearing from panelists. i also want to thank the ranking member. comments about access and the reminder that it's different in a large city and from a rural area or comments will take another one for us to remember carefully and also the reminder

can have different consequences, even in a state like massachusetts were obviously we have very extensive health care services in some areas, this still leaves us with part of the population in massachusetts but difficulties in accessing care. sometimes distant loves the challenge, the cost can remain a challenge and transportation with enclosed areas can be a serious challenge. i appreciate the reminder of the diversity of issues we face in making sure all of our citizen have access. thank you, mr. chairman. >> thank you, senator warren. >> thank you, mr. chairman. i would not use the allotted time in entirety and apologies to the panel he had to sneak out to attend another committee meeting in return for the q&a. i appreciate, mr. chairman, your

focus on the spot, the critical issue that is so much relevant to the implementation of the affordable care act. i represent the state that has urban concentrations as well as perhaps not as large spaces of rural areas, but certainly has the array of challenges that are the subject of this hearing and i appreciate the attention focused on it. one of the things i hope we will hear some aberration on aside from issues that compensation claim from a is the question of lifestyle for primary care practitioners, things like differences between the amount of time somebody might be on

call as a specialist versus a primary care physician if you look at larger payment reforms, and the practice of being able to spend adequate time with a patient with medical conditions that is necessary, versus seeing folks in 15 minute increments, and battery. what impact will this policy changes have on the number of primary care part dictionaries in this country? but anyway, mr. chairman, thank you for focusing attention and i hope to return and here for the witnesses to essay questions. >> thank you very much. senator franken. >> thank you, mr. chairman. this incredible hearing. we have 30 million more

americans we hope through medicaid, leaving some people still uninsured, red and testimonies last night and it is very clear that when you ensure people, their health care outcomes are better and that costs money when people are uninsured. what we are doing is so weird. sometimes her posture in this country. we can go to the emergency room. the most expensive health care and doesn't mean you get treated after the emergency room. doesn't mean you get what you need to treat a chronic condition. all of their testimony put a light that and i appreciate that. in minnesota we do help care

relative to the rest of the nation extremely well. hhs has rated us number one in high-value care and outcome provided by cost. we like wisconsin have a combination of urban, bars and not the miles and miles and miles and miles, but we have miles and miles. the ranking member, whom i'd like to welcome to the subcommittee and am looking forward to partnering with and i admire his word on rural health, which is so important in my state because there's people underserved. one of the things the chairman talked about was his student loans that graduating from medical school, a typical loan

debt of $160,000, sometimes more and then talking about the tendency for about dursban urges graduates to say, home and went to make this money quite we have coming in no, medpac and this is an issue in your case timoney. in our country, we pay specialists under ratio more than primary care physician and a in other countries that do their health care. successfully and cheaper and less expensively than we do. there's nothing good about the high cost of college and graduate school in my mind except the only probably could be is that create some tool for

us to motivate people to go into the things that we need. the one question i would like to panel to think about and i know you're going to give your testimony and were going to do questions. what is the return on investment if we say to doctors graduating medical school, doing some forgiveness, forgiveness for being a primary care physician in a rural area or underserved urban area, but what would be the return on investment if we really, really encourage dialogue forgiveness, doctors to go into primary care. in other words, what is the calculus affair? what is the equation if we raise -- if we say my goodness, it is such a benefit to society

in such a cost-benefit to have a higher ratio of primary care physician that if we said for anybody who goes in the primary care medicine, it's $100,000 rate their. with the cost benefits? it's good to see you, the reinhardt. dr. reinhardt and i have talked a number of times. he is a health care economist. maybe that's something you can ball over. i thank you, mr. chairman for this unbelievably importune hearing. >> thank you, senator franken. senator murphy. >> thank you, mr. chairman. excited to be with this committee and a fantastic panel and knock it out of the way so you can provide us with your testimony. let me say having chaired the house committee in the state

legislature, we grappled with this problem year after year. i remember specifically one meeting i had with maybe 15 or 20 medical students at the university of connecticut and at some point we were talking about the affordable care act and how it can help medical students talking about this issue of the high level of indebtedness. i asked how many of you are considering going into primary care. at the 15 students, one raise their hand. only one considered it. we started to examine the question as to why they did have it on their mind. certainly dollars for the first thing they mention. i would have indebtedness even out of state university and couldn't figure academy at work with the salary they would make as a primary care physician. as you start to tease a deeper answer from each one, the second thing was prestige, that they

did feel there was ropers teach any longer and a primary care physician. if you want to practice cutting-edge medicine coming you have to go into a specialty. they'll have an ego to put them on the front lines of the medicine. i hope that part of our hearing as well today is how we put the practice of medicine and primary care. had with them to be more than gatekeepers? they think is the perfect opportunity as we roll out new delivery system models in addition a world where countable care organizations and interconnect to practices or the rule rather than the exception only invest in things like medical home model's to allow for primary care physicians to once again control more medicine than they used to control. this teach comes back, maybe not so much in the medicine, the

control they have for the health care system system at large. as we build a new delivery system, it's an opportunity now to address the most critical question, which is how do they make their families budget work, but how did they get to feel good but the medicine they practice and the value adding to their profession because that's been lost as well as the first teach this specialists rather than primary care doc or is unimaginable examine that today. thank you, mr. chairman. >> thank you, mr. casey. >> thank you, mr. chairman. 20 thank you for calling this hearing. were gratefully to the word. the one quick comment is when we go to the attending physician as members of congress, where the doctor available to us in the capital and that the are in a sense is our quarterback, who

can make determinations about our health and refers to does that help us. one of the conclusions were one of the goals of all of this work in the hearing and otherwise this everyone has their primary care doctor, and a quarterback at midlife who can treat them, but also get them access to specialists and the best care. thanks. >> senator casey. senator hagan. >> thank you, mr. chairman. ranking member and the committee met for holding this hearing today. this is a critical issue facing our country today. in north carolina we have more than a million people who don't have asked is to primary health care because of a shortage of providers. i know when patients can see a primary health care doctor, they

frequently end up getting care obviously. what happens and i don't have that access, they go to the hospital and that's for emergency care and treatment is expensive and helping to drive up the cost of health care. if you've got a chronic disease and can manage the disease, otherwise they would develop into acute-care episodes. i know their innovations going on in this area and one is in north carolina. the blue ridge committee health services is a whole summer in the western part or if the. he received a grant this past november in the blue ridge space or 20,000 patients last year 3,070,000 encounters of primary care sites. for school-based health centers and windtunnel sumner. this funding the given has

allowed them to increase resonance at this facility in hendersonville and i think those residents are critical to providing, to helping with providing more primary health care physicians. blue ridge is one of 34 federally qualified to provide a high-quality care to so many people across the dates. i know there's another provision important and that is the pipeline that included in the affordable care act and against medical schools resources to recruit students from communities. so much of the primary care access is lacking in rural communities and if we can train physicians from those communities, and they tend to stay in communities, which is certainly a highlight of this provision. programs like that have a significant role to play in this primary care shortage.

i look forward to hearing the testimony of eyewitnesses today. >> thank you, senator hagan. senator whitehouse. >> thank you, senator sanders for holding this hearing. you've drawn a big crowd because it's an important issue. we are altering up in washington for the fiscal cliff, coming in a couple of weeks and with that i mean, we're beginning to hear the usual refrain about how important is to cut any care benefit and to limit access to medicare for seniors and that's the responsible thing to do to save money, which course is a preposterous and ill-informed media, particularly in the context of a health care system that is 100 times more unfit in the 60 and if you look at the graph, it's an accelerating curve of upper costs.

we look at a $2.7 trillion annual expenditure on health care, that is probably 50% higher. a 50% inefficiency penalty compared to all of our industrialized competitors, the worst industrialized competitors will% of gdp. we ate% of gdp. look at the scope of this, accelerated pace at the end raise any think you'll saw by cutting medicare? it's simply not right as the ceo kaiser permanente george halverson said, that is an inept way of looking about health care. it's not just wrong. it solon it's almost criminal. hearings like this to point out there's a problem with cost and delivery system in the united states and that we really have

to address that problem for not going to misdiagnose what we have and once you know you have a mistake is this coming usually don't the right cure either. it's really important that we not for seniors on medicare under the bus because they fail to address the real problem of health care, which is one of inefficient these and rocketing costs that are just in medicare. medicare is the most efficient delivery of health health care r health care system. if we get this right, 40% of savings will come back in the federal budget, but the rest will go to kaiser, blue cross community, this is families across the country. it's got a real fight to students in the right direction and i hope this hearing helps make the right choice. >> thank you very much. i want to nine members of the senate and viewers on c-span to

report on primary care access is available at the website standards.senate.gov. panelists have been patient, but good news of which he today is an enormous amount of interest in this issue. we're delighted that you're here in the thank you for the work you do. let's begin with dr. fitzhugh mullan. the murdoch health policy at the new school of public health and professor of pediatrics at the george washington university school of medicine. dr. mullan, thank you for being with us. >> thank you, chairman sanders, a great privilege to be here as a primary care for vision pediatrician who is in the first class of the national service corps 1972, subsequently ran has not only privileged, but astounding has terry to your

committee of the u.s. senate because such clarity about fewer finishes of primary care and service delivery in poor worlds and underserved communities. i will try to be cogent, the thank you for convening and i thought that's gone into this. i'm going to run through, chairman sanders come a day my talk. you're clearly the expert, so i'll stand in some of the things i was going to bring up to focus on issues of education and system building or on primary care. the demand clearly is in front of us. the teaching of the population, advent of the affordable care act and the entitlement it provides. that does present us with a challenge. just a few demographics. with 280 physicians in the united states, which puts us in the middle of the developed world. u.k. and canada have less in

germany and france have more. we are roughly in the middle and we have 800,000 physicians. additionally 190,000 nurse practitioners, physician assistants and midwives. almost a 25% out on the providers that didn't exist 30 or 40 years ago and appoint some unimportant member when our workforce is lame and talking in the 60s and 70s, we're very short and everybody agreed and began operating programs with some very powerfully today. among those for the development of the nurse tensioner and assistant that didn't exist before a national health health services core. silverman is not necessarily bad in terms of how we function if we want a more efficient system.

systems are used to the payment they currently get and they're not going to change until there's a real sense of need in there at that point. someone not for holding the rear now, we need to think about advantages and creativity that can come from this period. in terms of the primary care challenge, i look into ways. one is in the fact tree, medical school teaching hunt is on the other in the market and clearly we've had our contest money as to the pay parity gap that exists in both general terms, especially sony twice for a generalist makes. her pediatrician, family.com and internalized another disciplines that are generalist nature and poorly paid. that is a huge problem in the

education and training is important, what i do and believe in is the best education with this kind of incentives coming up to a repeating now. there got to do with that. speaking on the educational side, the challenges are at the middle-school level and residency of us recall this is important and very influential in the nature of the location of the position that comes out of the education pipeline. if paglia this point in time especially focused. a natural dominance of them are research oriented and specialty sciences, well represented for good reasons. but the primary care culture is often put in the back of the bus and you're not find care physician who has a mental by professor, you're too

intelligent come you're too smart to go to primary care. the culture is toxic and it's out there many to worry about it. the young doctor today suggested from lifestyle specialties. it is a proud with limited hours clear and refined knowledge requirement in a predictable life. one can understand those straws, but we need to work on that. finally have a sense of the social purpose and mission. medical schools have been well treated by nih to provide 17 or $18 million a year by medicare, which provides $10 million a year to teaching hospitals or presidency programs. about a hundred thousand her resume, very strong influence with no requirement in terms of workforce product at the other end. we put about $300 million into primary care. family medicine, pas and

300 million in the nationals service corps. 27 billion on one side is generally oriented and 600 million providing primary care careers. a huge amount began not surprising the outcome that results are not. the health center is referenced innovation is the paradigm at the hospital and importantly needs to guarantee. that is something that needs attention. the nurse practitioner is almost 190,000. the easily trained in large numbers and that's a very important feature of scaling a quick early. finally, the national workforce commission voted into the aca has not been funded, not matt. we need a better brain in our

system of etiquette bring to the day. i would be very helpful. we have a moral triumph in the aca and entitlement to bring, but also a technical challenge. in terms of legislative issues, permanent is important. the full funding and recounting of the health service court will be essential, bringing the commission to lead this important and perhaps most important is medicare gme. we need to get a handle it is the $10 billion in the more construct to probe primary care fashion. >> thank you very much. in order to have a question-and-answer period, if people could keep remarks to fire six minutes, that would be appreciated. next is tess kuenning come executive director of primary care association with a qualified health centers and vermont and new hampshire.

ms. kuenning, thank you for being with us. >> chairman sanders, ranking member and the members of the subcommittee, my name is tess kuenning -- on behalf of the entire health center community come including 22 million patients nationwide in the national association of committee held centers, to thank you for addressing the primary care access needs. as the committee is aware, two important events have significantly altered the financing and delivery systems of our nation of protection affordable care to the supreme court decision about the same. as a result of these events, it's estimated 30 million americans would gain coverage through medicaid and/or the health insurance exchange. yet another 30 million will still remain uninsured. we strongly support these coverage expansions which open

the door to broader health care system for many patients. however, we know coverage alone does not equate to access. access to regular care makes coverage meaningful. we believe to achieve a truly reformed health system, our nation needs sustainable solutions to an crease primary care capacity, laurie managed health care costs and ensure quality outcomes. at us for this reason in my view any effort to insurance escrow and expand our primary care infrastructure. community health offers a unique and proven solution to challenges. in a statute mission centers are located in underserved areas and serve medically underserved population and care for about regardless of ability to pay. how centers are directed a patient majority board ensuring care locally controlled response to an individual community needs. it may surprise you to learn

burlington vermont provides translation from sudan, bosnia, tibet, nepal to name only a few. the ability to receive care removes a major access barrier and improve the health of families and communities. premieres of practices in nepal, i'm able to speak nepali with refugee population and i see first-hand benefits of this enhanced provider patient relationship can yield. without access to primary care, many people including families might delay seeking treatment until their sears cl and require hospitalization or care in the emergency room at a much higher cost to themselves in the health care system. the literature backs of the six heiresses. the rural health article found the community health center at 25% fewer emergency room visits. other data demonstrate the

entire health system including government and taxpayers the $24 billion annually by keeping patients out of these health care settings. congress is the leadership -- fortunately, the chair had the foresight to include mandatory funding to expand the reach of the nations health centers the affordable care to ensure the promise of coverage was met with reality of care. we believe cms plan is essential. unfortunately the health center expansion is not currently on track. a recent solicitation for grants anticipates spending by $20 million of the $300 million in new fist are your funding, fiscal 13. the administration has proposed spending growth over a much longer period of time and we urge the full affordable care provided to increase full fiscal

year 13 be extended to care for 2.5 million new patient as congress intended. the demand for health center continues to outpace growth in more than 60 million americans still lack access to primary care. in vermont, new hampshire, all health centers have identified me in their areas. i'd be remiss if i failed to save another vital program that supports medical homes for underserved americans in the financial service corps. the core thesis the strain health professions in areas as a key partner in ensuring community health centers limit around the corner with dav implementation. how centers around the country are ready, willing, able to be leaders in reforming health to stem community by community from the ground up. we appreciate your leadership and look forward to your the committee's support for stewart to provide meaningful health

care access to all. thank you, mr. chairman. >> thank you, ms. kuenning. center as he will introduce a third witness. >> thank you, mr. chairman. it's my privilege to introduce ms. trained to. toni decklever we have 259 pounds come but only 14 tons of the population exceeds the elevation. [laughter] she's familiar with all of those and she currently wears several different professional hats. she's liaison for the wyoming nurses association is is a washington d.c. previous lee to advocate for fellow nurse is. ms. decklever hope to improve the work for us by recruiting and preparing for trade, technical and service occupations including help occupation. she's an independent consultant trained individuals in cpr, first aid, and how to become first responders.

she is about sheer science degree from university of northern colorado in greeley and a certified iain t. she's received awards for outstanding service on behalf of her her system work for us to student groups were pleased to have her here today. i know it took 13 hours in airplanes and airports readability get here. >> ms. decklever, thank you for being with us. >> good morning chairman sanders and members of the. thank you for the opportunity to testify today. i do rappers and the nurse association. up in a registered nurse for 30 years never to make you care, long-term care, education and frustration. wyoming is the ninth largest state in the u.s. i'm almost 100,000 square miles of land, better population is most of the nation with over half a million people.

wyoming is 25 hospitals for 16 designated as critical access hospitals. 25 beds are less. there's also two veteran hospitals in 16 rowhouse clinics. wyoming is a committee held senators special population and three satellites which are health care centers. when dealing with the expanded number of patients and barriers to care for patients come in several components to be considered. what is the ability for providers to the full scope of their education and licensure. another stooge retirement and shortage of qualified faculty to educate new providers. others include perception of quality of care in funding for rural areas. baby boomers turning 65 at 310,000 a day will be day will be an increasing in demand for health care in traditional acute care settings with one half of setting such as home health care. wyoming's practice back allows advanced part is coming nurse

practitioners to practice independently in our state. disability helps prevent patient in rural areas access to primary care. unfortunately common some limit the ability to practice a full scope. medicare law has kept home health care plans of care or home health benefit. and there is for access to physicians is limited, this has led to delays in home health services. moreover, it can lead to increased cost of the medicare system. this occurs in patients are unnecessarily left in his additional settings are readmitted after discharge because they did not receive proper home care. a sufficient supply of nurses is critical in providing our nation's population with quality health now and in the future. registered nurses are the bad run of hospitals, community

health clinics, school health programs, home health and long-term programs and serve many roles in finance. according to the 2008 national survey, over 1 million other nations 3.1 rvg 50. much like rural populations, the population is aging and the retirement age. the regional or sporadic growth of younger populations. that is identify retirement of providers is one of the obstacles to providing comprehensive care. wyoming responded to increasing needs by a funding stream that would assist nurse is at work of faculty at colleges and university. this allowed the programs to increase enrollment numbers and educate more registered nurses. our rents continue education to the advance their same old.

wyoming is a small amount of incentives and loan repayment money for students, the dollar amounts do not meet demand to reach finance. to fill the void, some students are able to receive funds from title eight and title vii. the perception that health care is delivered in better health centers equals quality is not easily overcome. many residents use health services and surrounding states who could've been served to address this issue in which we characterize the system by having a stable supply of providers. they integrate services at the point of care, medical home concept, collaborative planning and policy implementation. ..

>> this income disparity can

be another challenge to meet designation guidelines. thank you for your time and attention to this very, very important matter. i look forward to any questions you may have. >> thank you for being with us. our fourth witness, mr. wilper acting chief of medicine at boise idaho he is said practicing general internist was a ship program director of the residency program and the assistant director at the virginia center of excellence. thank you for being with us. >> thank you chairman sanders, ranking-member enzi and members of the committee is a great honor to testify here today i was asked about my insight specifically about the lack of feed is

states and the effective health care outcomes and also practical solutions for the primary care shortages that we face. there is enormous literature that has accrued over decades demonstrating a lack of health insurance was issued decrees access to health care has worse in comes. we summarize these findings in the sixth volume series and the conclusions were quite clear. build on this evidence that senator sanders mention specifically a papery published 2009 in the american journal of public health winking 45,000 deaths of with adults in the united states. it is consistent it is good for your health with those benefits. so gating health insurance

does not guarantee access which is the second part of my testimony nor does the control cost perhaps what we could do the national level to reduce cost with regard to health as bolster the primary care work force. ears and a dissident -- additional massive body of literature showing that primary-care helps the outcome but we have not seen systematic changes to zero libby -- to alleviate those numbers over the decades. i will talk about the three policy levers that i see that this committee could consider with a primary care physicians entering the workforce. first, at the medical school level and people are in undergraduate training we introduce additional debt

reduction and change federal funding streams to increase funding swarthy full-service score in direct support to kennedy service to encourage 34th year to enter into primary care also a graduate medical education title seven is specifically earmarked to go toward primary care programs and these are continuously under threat of congressional cut the last 10 years. to emphasize that funding would be an important step. the second piece is direct payments by medicare to teaching hospitals to offset the training positions we heard nearly $10 billion is spent to support these hospitals but currently we have no planning in place to actually meet the needs of our population in canada states with the work force.

medicare should direct it to your education some hospitals also require assessments for hospitals to qualify and in its current form it is run by teaching hospitals to meet their own needs saying graduate select field of pac -- practice based on their personal interest and i have been told directly it is not based on the population health needs and the best policy reforms could make is to address trade -- paid disparity between primary-care or specialist i really feel that is the disparity that is the driving force in this work force problem that we face today. the cop american medical colleges says the training

cannot overcome physician traces. traces. as the subcommittee of the ama relative value scale, a secretive group of doctors that wields tremendous influence over medicare reimbursement rates and cms of jobs nearly all recommendations at a minimum the public deserves transparency and establish a process that is not encumbered by conflicts of interest and does not favor specialties one might conclude that the government and the ama are colluding to bring an end to the primary health care positions in unix states better care reform efforts leave 30 million uninsured and i have worked for over a decade in medical education as a student residence fellow and it is my a belief

it should be planned to meet the health kim needs of the population first is the staffing preferences of hospitals of a lifestyle preferences of doctors. >> understanding is mr. franken has to leave? >> thank you, mr. chairman. yes. [laughter] you are talking about the compensation, you probably heard my comment earlier about the return on investment in terms of loan forgiveness or primary care physicians. what would that look like? in other words, , i know be

do some loan forgiveness what would that look like in terms of the value you get back over the course of a physician's career? if you are a gp, $100,000 per year. has that been looked at? >> senator, a thank you for the question coming to my knowledge there is no systematic review. in my home state of idaho and neighbors to wyoming we do have programs in place to help offset education related to medical education and i would refer to my panelist.

>> may ask you that? >>. >> if you have more primary-care physicians that will improve access and it shows that will produce better health and life year's end economists can put that into quality adjustment. usually the assumption is the value is put with that i know they use $100,000 to put a value on it then say by having more physicians in that field, providing better access how many have you produced with better quality of life? and you would get the return that i suspect is fairly

high. or i would ask a student. >> i just have to minutes left and then i will go. >> that is all you have any way. >> that is what i meant. i would like those three seconds back. and to senator murphy's comment about the status, i think your status is partly determined by your salary. so i do think that the relative value that you talk about, in other countries what is the compensation like in terms of general practitioner to specialist? is it different?

i mean is a ratio higher from general practitioner from spacious -- specialist for here? >> the specialist to earn more in germany but not as much as they do here. cheapies generally to have lower pay and occasionally protest about that it happens over there but i don't think the ratio is quite as large. >> they have lower health care cost and as good as outcomes if not better? >> about half. >> the health care cost. senator murphy brought this up accountable organizations in our state and in the medical homes, would they

elevate the role of the general practitioner in that model to organize this team that does the care? does anybody have an opinion on that? >> specifically with that a ceo's hamas the fee-for-service payment mechanism is changed and there is a proposal to do that with the medical home models, there is some chance that would move then you go with primary care physician reimbursement precaution we know this research fairly well there is some limited evidence that it would reduce cost so that intervention while were the, at the state level and at the v.a. is experimental. >> okay. i am sorry.

mr. chairman for that and one last thing, ms. decklever i thought it was really off base for the ranking member to show your willingness to come here to testify to moan about his weekly commute. [laughter] >> let me introduce a man who has already spoken, a dr. reinherdt with a professor of economics at princeton university and a contributing writer from "the new york times." dr. reinherdt thank you for being with us. >> i am very honored, i should have added i was

delivered by a midwife and i once told that to a member of the medical community and he said it shows. i have provided mike written statement into three parts and one is to be efficiently use did i thank you have heard from the panel the answer is no. the second is what public policy lever does congress have that we want more primary-care physicians to move them into that field with they are needed? the third question is to what extent do financial incentives which you have already answered and talked about. the traditional model of work force has been the focus on physician

population ratios as those who work in their primary care team did not matter. my whole career has been to say we should flumes workers far more imaginatively and let them work independently of full competition with physicians. that was very controversial many years ago but now many states allow that. congress has played a large role to innovate in this field by funding the training of bears practitioners and physician assistants and creating community health centers and other settings or they can very effectively be in use and licensing issues congress could address. usually it is excused with

appeal to a patient safety and quality. but i think it is mainly over economic terms. i remember whether -- could dilate pupils. those are the issues that is the war that has to be fought and i think congress should simply make sure that licensing is driven and economic considerations. and not on economic tear there is the issue, of the scopes a practice that has huge variations and i believe with the nursing profession there should be a standard for the nation which should allow nurses to

practice. physician assistants by their nature actually are supervised by physicians. and how can you drive physicians when you need them in these teams into primary care, the issue of christie's in senator murphy mentioned the new models of primary care were quite natural to enhance the power, not just money but power, they are not gate keepers but in those settings, i told that to our daughter who was an internist yesterday that i would be excited to be of primary care physician now. the entrepreneurial

opportunities are limitless compared to other specialties. with the final point*, compensation is clearly an issue. mr. chairman camille mentioned over a lifetime it is such a small son when you think of the managing director with the annual bonus but that probably would do something because it is a single value to people. that should definitely be done. it is like the national health service corps and every year you practice or if you go into specialized primary-care, 80,000 up

front then you specialize in the location, we will forgive 20,000 to have the incentive out there. finally, when we allow private equity managers to take a commission with capital gains tax on carried interest, i said why don't we care primary-care physicians as the honor managers saying give them the same rate if they go to the rural area, it, etc.? the president exist but congress says carried interest we want to encourage capital formation. while that is capital physicians are human capital and we want to encourage that. thank you, mr. chairman. >> glass but not least we

have dr. fegan the chief medical officer at cook county hospital in chicago press the the associate chief medical officer for the cook county ambulatory network and interim chief medical officer at the bureau of health services. and received an undergraduate degree from forest and also you dollars of illinois college of medicine. thank you for being with us. >> thank you chairman sanders, ranking-member enzi for affording me this opportunity to address inadequate access to primary care in the united states as the chief medical officer in chicago most do those people as cook county hospital i confronted daily basis our failure to provide universal access to health care as a right to which i believe

everyone is entitled. every single day people without a physician lineup to be seen in the walk-in clinic. tens of thousands, hundreds of people per week stand out in the wee hours of the morning hoping to see the 120 people that will be seen were hoping to be one of the 12 who are assigned as primary care physician to give an appointment not to come back. i hope to be lucky one to be given the position of there very own. our current influenza epidemic shows the patchwork for health care delivery. too few people have access to primary care provider it has educated them about insolence of and especially to vote populations and in context. in the primary care provider could give them that vaccine. instead tens of thousands

attend the emergency rooms are sick of looking for how. at the peak we were seeing 450 people per day while hospitals around the country closed doors and went on bypass. at county we never go on bypass. we never close our doors. we created the air via system to compensate and hoped it would level the playing field between primary-care physicians in procedure based specialists but the update committee was reviewing how medicare compensates positions was only allocated for primary care with the team members rates to and to increase the number of primary care physicians but when graduate medical education and hospitals i -- we disperse

the same amount but if we increase hospital reimbursement for primary-care physician in training, we will have more primary care physicians. you can do that. the have the privilege of being a primary care physician myself. love taking care of patients. they invite me into their lives as they teach them to take care of themselves. the daughter of a labor union organizer and social worker could never afford medical school progress fortune enough to be part of the national health service corps that paid for my a medical education so i could follow my passion to become primary care physician not wearing how to pay off my loans. but if medical students know before they begin they have no debt upon completion they'll be more likely to make the decision in primary care rather than highly compensated specialties. but it is up product of our

fragmented and dysfunctidysfuncti onal financing health care with public and private payers including hundreds of plants each with its own set of rules including primary care with exit from our profession. with the national health care program for everyone is entitled to health care we focus on delivering the best care in the world to our patients and alleviate hassles for proper billing services. the stresses on the physicians are tremendous with the electronic health records that makes them spend more time looking at the computer than at the patient's. most e. our systems are for billing not for care. as a result it runs precious time from the physician that they would rather spend engaging with the patient to

understand there need. there is no question if we had designed it for clinical care it would be a very different tool. there are tools for patient safety been far more demand for documentation and will use the narrative of the individual patient to approve the point* and click for billing. i urge you to work to make a difference, not for me or you but the patients i have the privilege of serving who desperately need elected officials to care about what happens to them. thank you. >> thank you very, very much, a dr. fegan. let me begin the questioning. i want to ask two brief questions. my understanding is, if i have the flu or any merchant illness that i walked into the emergency room it will cost medicaid 10 times more

than for me to walk into a medical health center? there are millions of americans that people get sick and think they get better didn't go to the doctor then the doctor says why weren't you here six months ago? and have to get you to a hospital. how much money in human suffering is taking place in this country because people are unable to walk into a doctor's office when they need to? >> i can just tell you about the faces of the patients that line up to be seen on a daily basis. i don't know how you measure said costas suffering that people come to a county because you see things joyner-kersee anywhere else

such advanced stages of disease everything from brain tumors or lesions the erupting and you ask why did you stay home? i will tell you these people are working folks college professors, accountants, att orneys in the first thing they say is i never thought i would be here at the county. i would say it has to be millions of dollars was work-force productivity as well as suffering for crises so many patients get breast cancer and lose jobs and come to us to get for their treatment and they have lost their homes by the time they get to us we figure out how to get started on chemotherapy and a place to live in a.

>> line know from stories, i cannot put a dollar in equations but we have so many stories we have a farm worker program that works with the farmers who aren't coming in for care river 50 year-old who has a history of diabetes and has never seen a doctor and does not know they could give care on a sliding fee discount that is to understand both the cultural issues and get them into care. >> let me touch on the important issue to determine reimbursement rates the word that is probably not a household word but it plays an enormous role to determine